The relevance of cultural diversity on safety culture: a CIRS data analysis to identify problem areas and competency requirements of professionals in healthcare institutions.

Aim: The society and consequently also the health system have become increasingly culturally diverse which applies to both – patients and professionals. Studies indicate an influence of the ethnicity on the care context. With regard to this, considerably more knowledge is available regarding diversity among patients than among professionals, for example considering the effect of cultural diversity in teams. The impact of cultural diversity on patient safety has barely been investigated which means that potential effects as well as required measures and competencies cannot currently be specified. As part of the project “Gestaltungskompetenz als Innovator für hochzuverlässige Organisationen im Gesundheitssystem” (abbreviation: GIO, “Gestaltungskompetenz as an Innovator for High Reliability Organisations in the Healthcare System”) these questions are investigated in the context of a case study. Therefore, a CIRS data analysis was carried out to identify specific problem areas to derive competencies for the safe handling of cultural diversity between employees. On this basis and adjusted to the target group, an interactive learning management system will be developed for the advanced training of professionals. Method: For the topic of cultural diversity, an analysis of the patient safety cases reported in CIRSmedical (Critical Incident Reporting System) was carried out followed by a qualitative summarising content analysis. The systematic search in CIRS was based on previously defined search terms as well as inclusion and exclusion criteria. Results: 45 cases were included in the analysis. The results can be classed into two categories: “(Unsuccessful) communication” and “Unsuccessful adaptation to patient needs”. Cultural diversity was not usually named as a primary or explicit cause but usually a combination of several factors was given as the reason for the occurrence of an undesirable event. Conclusion: The analysis of CIRS data identified concrete challenges resulting from the intercultural composition of teams and in the care context. The approaches for improvement should include both, organisational and personnel measures. In case of the latter, it is essential that competency requirements are identified resulting in suited offers for the competence development in the course of initial and professional development training for medical and nursing staff in ethnically diverse teams.


Introduction
The relationship between migration and health is multicomplex. It includes both, the experience and the occurrence of complaints and illnesses, as well as the perception and the utilisation of the health system [1], [2]. Ethnicity influences both, the patients as well as the professionals and due to the growth of cultural diversity it be-comes high priority [3]. Culturally sensitive communication is particularly important in this context [4]. Existing concepts such as "(inter-)cultural competency" or "intercultural communication" mostly focus on the patients but rarely on the professionals [5], [6]. Additionally, in the context of patient safety, communication is of key importance [7], [8].
However, there is barely any information available on the influence of cultural diversity on patient safety or the safety culture in health facilities [9], [10]. It therefore remains uncertain, whether specific competencies are required for a patient safe handling of ethnically diverse patients. Furthermore, little is known about which influence cultural diversity has on the patient safety (positive or negative) and whether, or which culturally sensitive competencies employees working in heterogeneous teams require to ensure a patient safe working environment. For this purpose, the CIRS data analysis was carried out following the research question: "Which problem areas are reported in CIRSmedical in the context of cultural diversity?"

Project description
In the context of the joint project "Gestaltungskompetenz als Innovator für hochzuverlässige Organisationen im Gesundheitssystem (GIO)" (="Gestaltungskompetenz as an Innovator for High Reliability Organisations in the Healthcare System") the influence of cultural diversity on the safety culture is investigated in a case study. The overreaching aim of the case study is to identify competencies for the safe handling of cultural diversity among employees and to use the results as the basis for the development of an interactive training offer. For this purpose, an analysis of patient safety cases reported in CIRSmedical (Critical Incident Reporting System) was carried out with regard to the topic "Ethnicity" [11]. For the systematic search the following search terms were used: "Migra*", "Migri*", "Herkunft" ["origin"], "Ethni*", "Ausland" ["foreign"] or "Ausländ*" ["foreign"]. The CIRSmedical database comprised a total of 5,786 cases (as of 11th Jan 2018), with 190 cases identified by means of the used key words. After 145 cases had been excluded, 45 cases were included in the summarising qualitative content analysis according to Mayring [12]. The cases were independently evaluated by two scientists. Disagreements with regard to the inductively developed categories during the qualitative content analysis were resolved by consensus.

Results
The analysis of CIRS data showed, that problem areas linked to cultural diversity are often reported as causal for the undesirable event (next to others such as organisational factors). In 13 case descriptions, cultural diversity is named as the main factor for the issue and in ten cases it is named as a contributing factor. In 23 cases, cultural diversity is mentioned as a factor that is assumed to be contributing. For instance, next to a wrong medication, also language barriers contributed to an undesired event.
The 45 identified cases were divided into two categories: "(Unsuccessful) communication" and "Unsuccessful adaptation to patient needs" (see figure 1). In the latter category, a deviation from the standard procedure was made on account of patient needs. The patient safety was put at risk on account of respect for a patient's religion, which inhibited a marking of the limb to be operated. The category of "(Unsuccessful) communication" has been further subdivided in "Employee-employee communication" (1) and "Employee-patient communication" (2). The former includes cases in which information was insufficiently passed on, e.g. on account of language or labelling deficits. The latter includes cases which become apparent on account of language barriers such as general patient communication, the admission of patients and patient identification.

Discussion
The results of the CIRS data analysis show that, due to communication problems in culturally diverse teams as well as difficulties caused by a lack of intercultural interaction, processes and therefore also patient safety can be put at risk. The approaches to improvement should include both, organisational and personnel measures. In case of the latter, it is essential that competency requirements are identified and suited offers for the competence advancement are developed for medical and nursing professional development training. In the following, the GIO project uses the inductively derived classifications to develop competency requirements and corresponding learning targets (see figure 2), which in the next step will become the basis for the development of training offers in form of an interactive online learning environment. This is carried out on the basis of a competency catalogue developed in the GIO project. This competency catalogue is the first approach to specify competencies for the development of a safety culture, in the sense of a high reliability organisation. Limitations of the study are illustrated by the data protection and anonymisation of the cases in the CIRS database, edited by authorised employees of ÄZQ (Ärztliches Zentrum für Qualität in der Medizin=Agency for Quality in Medicine) in order to ensure, for instance, a description free of discrimination. Therefore, it is possible that additional problem areas remain undiscovered. However, the CIRS data analysis allows the assumption that culture and especially the communication on employee level are closely connected with and highly relevant for patient safety.

Conclusion
The CIRS data indicates that heterogeneity in healthcare and in particular communication represent competency requirements, for both, culturally heterogeneous teams as well as in the care of culturally diverse patients. How-